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Ejaculatory Disorders

Ejaculatory Disorders is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Premature ejaculation (PE): inability to control ejaculatory reflex resulting in ejaculation sooner than desired; most common type of sexual dysfunction affecting all age groups:
    • Defined (ISSM 2007) as an ejaculation that always or nearly always occurs prior to or within 1 minute of penetration; an inability to ejaculate on all or nearly all penetrations and with negative personal consequences (1,2)
    • Natural biologic response is to ejaculate within 2 to 5 minutes after vaginal penetration.
    • Ejaculatory control is an acquired behavior that increases with experience.
  • Delayed ejaculation (DE): prolonged time to ejaculate (>30 minutes) despite desire, stimulation, and erection
  • Aspermia (lack of sperm in the ejaculate):
    • Anejaculation (AE): lack of emission or contractions of bulbospongiosus muscle
    • Retrograde ejaculation (RE): partial or complete ejaculation of semen into the bladder
    • Obstruction: ejaculatory duct obstruction or urethral obstruction
  • Painful ejaculation: genital or perineal pain during or after ejaculation
  • Ejaculatory anhedonia: normal ejaculation lacking orgasm or pleasure
  • Hematospermia: presence of blood in the ejaculate
  • Ejaculatory duct obstruction
  • Synonym(s): rapid ejaculation; retarded ejaculation; inhibited orgasm in males; ejaculatory dysfunction

Epidemiology

Prevalence
  • PE is common. Reported prevalence in U.S. males ranges from 20% to 30% depending definition.
  • DE is reported in 5–8% of men age 18 to 59 years, but <3% experience the problem for >6 months.
  • Predominant age: all sexually mature age groups
  • Predominant sex: male only

Etiology and Pathophysiology

Male sexual response:

  • Erection mediated by parasympathetic nervous system
  • Normal ejaculation consists of three phases:
    • Emission phase: Semen is deposited into urethra by contraction of prostate, seminal vesicles, and vas deferens; under autonomic sympathetic control
    • Ejaculation phase: Semen forcibly propelled out of urethra by rhythmic contractions of bulbospongiosus and ischiocavernosus muscles. This is mediated by the somatic nervous system on the motor branches of the pudendal nerve. Bladder neck contracture induced by α-adrenergic receptors ensures anterograde ejaculation.
    • Orgasm: the pleasurable sensation associated with ejaculation (cerebral cortex); smooth muscle contraction of accessory sexual organs; release of pressure in posterior urethra
  • PE has many theoretical causes:
    • Penile hypersensitivity
    • 5-Hydroxytryptamine (5-HT) receptor sensitivity
    • Sexual inexperience
    • High level of sexual arousal and/or long interval since last ejaculation
    • Fear of sexual transmitted infections (STIs)
    • Anxiety or guilty feelings about sex
    • Lack of privacy
    • Interpersonal maladaptation (e.g., marital problems, unresponsiveness of partner)
  • DE:
    • Rarely due to underlying painful disorder (e.g., prostatitis, seminal vesiculitis)
    • Psychogenic
    • Sexual performance anxiety and other psychosocial factors
    • Medications may impair ejaculation (e.g., MAOIs, SSRIs, α- and β-blockers, thiazides, antipsychotics, tricyclic and quadricyclic antidepressants, NSAIDs, opiates, alcohol).
  • Never any ejaculate:
    • Congenital structural disorder (müllerian duct cyst, wolffian abnormality)
    • Acquired (radical prostatectomy, postinfectious, posttraumatic, T10–T12 neuropathy)
  • AE:
    • Retroperitoneal lymph node (LN) dissection
    • Spinal cord injury or other (traumatic) sympathetic nerve injury
    • Medications (α- and β-blockers, benzodiazepines, SSRIs, MAOIs, TCAs, antipsychotics, aminocaproic acid)
    • Diabetes mellitus (DM) (neuropathy)
    • Radical prostatectomy
  • RE:
    • Transurethral resection of the prostate (25%) or other prostate resection procedures
    • Surgery on the neck of the bladder
    • Extensive pelvic surgery
    • Retroperitoneal LN dissection for testicular cancer (also may produce failure of emission)
    • Neurologic disorders (multiple sclerosis [MS], DM)
    • Medications (α-blockers, in particular tamsulosin, ganglion blockers, antipsychotics)
    • Urethral stricture (may be posttraumatic)
  • Painful ejaculation:
    • Infection or inflammation (orchitis, epididymitis, prostatitis, urethritis)
    • Ejaculatory duct obstruction
    • Seminal vesicle calculi
    • Obstruction of the vas deferens
    • Psychological/functional
  • Ejaculatory anhedonia:
    • Medications
    • Psychological
    • Hormonal imbalances
    • Decreased libido
  • Hematospermia (often unable to find cause):
    • Inflammation/infection
    • Calculi: bladder, seminal vesicle, prostate, urethra
    • Trauma to genital area (cycling, constipation)
    • Obstruction
    • Cyst
    • Tumor (prostate cancer [1–3% present with hematospermia])
    • Arteriovenous malformations
    • Iatrogenic
    • Hypertension

Commonly Associated Conditions

  • Neurologic disorders (e.g., MS)
  • DM
  • Prostatitis
  • Ejaculatory duct obstruction
  • Urethral stricture
  • Psychological disorders
  • Endocrinopathies
  • Relationship/interpersonal difficulties

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Citation

Stephens, Mark B., et al., editors. "Ejaculatory Disorders." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116202/all/Ejaculatory_Disorders.
Ejaculatory Disorders. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116202/all/Ejaculatory_Disorders. Accessed April 26, 2019.
Ejaculatory Disorders. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116202/all/Ejaculatory_Disorders
Ejaculatory Disorders [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 26]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116202/all/Ejaculatory_Disorders.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Ejaculatory Disorders ID - 116202 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116202/all/Ejaculatory_Disorders PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -